FORMAT PENGKAJIAN ANTENATAL

Nama               :NIM                 :Tgl praktek      :

A.     Data Demografi1.   Nama klien                             :2.   Umur klien                             :3.   Jenis kelamin                         :4.   Alamat                                   :5.   Status perkawinan                  :6.   Agama                                    :7.   Suku                                       :8.   Pendidikan                             :9.   Pekerjaan                               :10.  Nama suami                          :11.  Umur suami                          :12.  Tanggal periksa                     :13.  Tanggal pengkajian               :

B.     Keluhan Utama Saat Ini

________________________________________________________________________                ________________________________________________________________________________________________________________________________________________     ________________________________________________________________________

C.     Riwayat Penyakit Dahulu

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

D.     Riwayat Penyakit Keluarga

 ________________________________________________________________________________________________________________________________________________

E.     Riwayat Ginekologi

________________________________________________________________________________________________________________________________________________     ________________________________________________________________________________________________________________________________________________________________________________________________________________________

F.      Riwayat Obstetri1.      Menstruasia.      Menarche                        : __ tahunb.      Siklus menstruasi            : ____ hari lamanya __ haric.      Karakteristik                   :______________________________________________2.      G  P  Aa.      HPMT                             :______________________________________________b.      HPL                                :______________________________________________c.      Usia kehamilan               :______________________________________________

3.      Keluhan yang muncul selama kehamilan iniTrimester Keluhan

I

II

III

4.      Riwayat kehamilan dan persalinan yang laluNo Tahun

LahirTipe

PersalinanLama/Proses

Persalinan

Tempat/Penolong

Persalinan

BBL Kondisi Saat

Lahir

Masalah Nifas & Laktasi

Komplikasi Selama

Kehamilan

G.    Kebiasaan yang Merugikan

________________________________________________________________________     ________________________________________________________________________________________________________________________________________________

H.    Imunisasi

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I.       Kebutuhan Dasar

1.      Nutrisia.       Pola makan, frekuensi, jenis, jumlah

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

b.      Perubahan pola makan selama hamil____________________________________________________________________________________________________________________________________

c.       Alergi makanan____________________________________________________________________________________________________________________________________ .

d.      Minum jumlah dan jenis____________________________________________________________________________________________________________________________________

e.       Keluhan yang berhubungan dengan nutrisi__________________________________________________________________ . 

2.      Eliminasia.      Buang air kecil

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

b.      Buang air besar     __________________________________________________________________     __________________________________________________________________________________________________________________________________________

3.      Aktifitas dan latihana.      Aktifitas selama hamil

__________________________________________________________________                 

b.      Keluhan dalam beraktivitas____________________________________________________________________________________________________________________________________

4.      Istirahat dan tidur____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5.      Seksualitas_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6.      Persepsi dan kognitifa.      Status mental                  :______________________________________________b.      Sensasi

1).    Pendengaran             :______________________________________________2).    Berbicara                  :______________________________________________

     _______________________________________________________________3).    Penciuman                :_____________________________________________ .4).    Perabaan                   :_____________________________________________ .5).    Kejang                      :_____________________________________________ .

6).    Nyeri                        :______________________________________________                         ______________________________________________________________     

7.      Persepsi dan konsep diria.      Motivasi terhadap kehamilan

______________________________________________________________________________________________________________________________________________________________________________________________________

b.      Efek kehamilan terhadap body image______________________________________________________________________________________________________________________________________________________________________________________________________

c.      Orang yang paling dekat__________________________________________________________________

d.      Tujuan dari kehamilan______________________________________________________________________________________________________________________________________________________________________________________________________

J.      Keluarga Berencana

________________________________________________________________________________________________________________________________________________________________________________________________________________________

K.    Pemeriksaan Fisik

1.      Tanda-tanda vitala.      Tekanan darah                : _________ mmHgb.      Nadi                                : __________ kali/menitc.      Temperatur                     : _______________d.      Respirasi rate                  : _____________kali/menit.

2.      Status gizia.          Berat badan                    : __________ Kg sebelumnya hamil ______________ kgb.         Tinggi badan                   : ________ Cm.

3.      Kulit, rambut, dan kukua.      Inspeksi kulit:_______________________________________________________4.       a.      Inspeksi kuku dan rambut:_____________________________________________

                       _________________________________________________________                                                    _________________________________________________________                                                    

5.      Kepala dan lehera.       

Mata:______________________________________________________________________________________________________________________________________     Telinga: ___________________________________________________________________________________________________________________________________Leher:_____________________________________________________________________________________________________________________________________

6.      Mulut, tenggorokan dan Hidung :a.      Inspeksi mulut:______________________________________________________     

                 b.      Inspeksi tenggorok:__________________________________________________

__________________________________________________________________                 

c.      Inspeksi hidung:_____________________________________________________                 

 

7.      Thoraks dan paru-parua.      Inspeksi:___________________________________________________________

__________________________________________________________________                             

b.      Palpasi:____________________________________________________________                             

c.      Perkusi:___________________________________________________________                            

d.      Auskultasi:___________________________________________________________________________________________________________________________

8.      Payudaraa.      Inspeksi:___________________________________________________________

_____________________________________________________________________                       

b.      Palpasi:____________________________________________________________                      

9.      Jantunga.      Inspeksi:___________________________________________________________

                   b.      Palpasi:____________________________________________________________

                 c.      Perkusi:___________________________________________________________

                 d.      Auskultasi:_________________________________________________________

                10.  Abdomen

a.          Inspeksi:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

                         b.      Palpasi:1).    Leopold I                  :______________________________________________

                                _______________________________________________                                _______________________________________________

2).    Leopold II                 :______________________________________________                                        ______________________________________________

3).    Leovold III               :______________________________________________4).    Leopold IV               :_____________________________________________ .5).    Auskultasi DJJ          : ______________________________________kali/menit6).    Tafsiran berat janin   : TFU-12 Cm x 155 gr

                                         ______-12 x 155= ______ gr.11.  Genetalia

__________________________________________________________________________________________________________________________________________

12.  Anus dan rektum__________________________________________________________________________________________________________________________________________

13.  Vaskularisasi perifera.      Inspeksi wajah dan ekstremitas:_________________________________________b.      Perkusi refleks tendo:_________________________________________________

14.  Muskuloskeletal__________________________________________________________________________________________________________________________________________

15.  Neurologik__________________________________________________________________________________________________________________________________________

L.     Pemeriksaan Laboratorium atau Hasil Pemeriksaan Diagnostik Lainnya

Tanggal dan Jenis Pemeriksaan

Hasil Pemeriksaan Interpretasi

M.   Terapi Medis yang Diberikan

Tanggal Jenis Terapi Rute Terapi Dosis Indikasi Terapi